Care-seeking for difficulties conceiving in sub-Saharan Africa: findings from population-based surveys in eight geographies.

STUDY QUESTION: What is the nature of women's care-seeking for difficulties conceiving in sub-Saharan Africa (SSA), including the correlates of seeking biomedical infertility care at a health facility? SUMMARY ANSWER: Care-seeking for difficulties getting pregnant was low, much of which involved traditional or religious sources of care, with evidence of sociodemographic disparities in receipt of biomedical care. WHAT IS KNOWN ALREADY: Nearly all research on infertility care-seeking patterns in SSA is limited to clinic-based studies among the minority of people in these settings who obtain facility-based services. In the absence of population-based data on infertility care-seeking, we are unable to determine the demand for services and disparities in the use of more effective biomedical sources of care. STUDY DESIGN, SIZE, DURATION: We used cross-sectional, population-based data from the Performance Monitoring for Action (PMA) female survey in eight geographies in SSA, including nationally representative data from Burkina Faso, Côte d'Ivoire, Kenya, and Uganda and regionally representative data from two provinces in the Democratic Republic of the Congo (DRC) (Kinshasa and Kongo Central) and two states in Nigeria (Kano and Lagos). We employed a multi-stage cluster random sampling design with probability proportional to size selection of clusters within each geography to produce representative samples of women aged 15-49. Samples ranged from 1144 in Kano, Nigeria, to 9489 in Kenya. PMA collected these data between November 2021 and December 2022. PARTICIPANTS/MATERIALS, SETTING, METHODS: We restricted the sample to women who had ever had sex, with analytic samples ranging from 854 in Kano to 8,059 in Kenya, then conducted descriptive and bivariable analyses to examine characteristics of those who sought care for difficulties getting pregnant. Among those who reported seeking care, we conducted bivariable and multivariable logistic regression analyses to determine factors associated with receipt of biomedical services from a health facility. All analyses were conducted separately by geography. MAIN RESULTS AND THE ROLE OF CHANCE: Our study found low levels of care-seeking for difficulties getting pregnant among sexually active women in eight geographies in SSA, ranging from 3.7% (Kenya) to 15.3% (Côte d'Ivoire). Of this, 51.8% (Burkina Faso) to 86.7% (Kinshasa) involved receipt of biomedical services in health facilities. While many factors were consistently associated with infertility care-seeking from any source across geographies, factors associated with receipt of biomedical care specifically were less pronounced. This may be a result of the highly limited sources of infertility services in SSA; thus, even privileged groups may struggle to obtain effective treatment for difficulties getting pregnant. However, we did observe disparities in biomedical care-seeking in our bivariable results in several geographies, with the wealthiest women, those with more education, and those residing in urban areas generally more likely to have sought biomedical care for difficulties getting pregnant. LIMITATIONS, REASONS FOR CAUTION: Our data lacked details on the nature of the services received and outcomes, and we do not have information on reasons why women chose the sources they did. Small samples of women who sought care limited our power to detect significant differences in care-seeking by women's characteristics in several geographies. WIDER IMPLICATIONS OF THE FINDINGS: Infertility and access to appropriate treatment are issues of reproductive health and human rights. While our results do not indicate to what extent use of non-biomedical sources of care is driven by preferences, cost, or lack of accessible services, it is clear from our results and existing literature that more needs to be done to ensure access to affordable, quality, cost-effective infertility services in SSA. STUDY FUNDING/COMPETING INTEREST(S): This study was supported by grants from the Bill & Melinda Gates Foundation (INV009639) and the National Institute of Child Health and Human Development (K01HD107172). The funders were not involved in the study design, analyses, manuscript writing, or the decision to publish. The authors have no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: N/A.

Direct and indirect estimation of adolescent sexual intercourse and contraceptive use in Rajasthan India: an application of the best friend methodology.

BACKGROUND: Existing estimates of adolescent sexual and reproductive health (ASRH) behaviors may be a gross undercount given the sensitivity of this behavior in Indian culture. The objective of this study was to estimate ASRH behaviors in Rajasthan, India using direct questions and the best friend approach that seeks to reduce social desirability bias. METHODS: We used population-based data of adolescents aged 15-19 in Rajasthan collected between September and December 2022. Data include whether the respondent and her closest female friend ever had a partner, ever had sex, ever used contraception, and were currently using contraception. We estimated respondent and best friend ASRH outcomes separately, overall and among unmarried adolescents for whom we anticipate social desirability bias is greatest. RESULTS: The best friend approach performed well, with method assumptions largely met even before adjustments. Respondent and best friend estimates were similar among all adolescents except for current contraceptive use, which was higher for friends (though not significantly so). However, we observed large differences in ASRH behaviors between unmarried respondents and friends, with a significantly higher percentage of friends who ever had a partner (4.3% respondents, 11.6% friends), and a slightly higher percentage who ever had sex (2.4%, 3.8%) and who were currently using contraception (17.0%, 19.7% among those in need of contraception). CONCLUSIONS: We observed potential benefits of using the best friend methodology in estimating premarital sexual activity, but further work is needed to refine social network-based measures of sensitive adolescent behaviors in larger study samples to better understand ASRH needs.

Postabortion care service availability, readiness, and access in Burkina Faso: results from linked female-facility cross-sectional data.

BACKGROUND: Little is known about postabortion care (PAC) services in Burkina Faso, despite PAC's importance as an essential and life-saving component of emergency obstetric care. This study aims to evaluate PAC service availability, readiness, and accessibility in Burkina Faso. METHODS: Data for this study come from the Performance Monitoring for Action (PMA) Burkina Faso project and the Harmonized Health Facility Assessment (HHFA) conducted by the Institut de Recherche en Sciences de la Santé and the Ministry of Health. PMA data from a representative sample of women aged 15-49 (n = 6,385) were linked via GPS coordinates to HHFA facility data (n = 2,757), which included all public and private health facilities in Burkina Faso. We assessed readiness to provide basic and comprehensive PAC using the signal functions framework. We then calculated distance to facilities and examined percent within 5 kms of a facility with any PAC, basic PAC, and comprehensive PAC overall and by women's background characteristics. RESULTS: PAC services were available in 46.4% of health facilities nationwide; only 38.3% and 35.0% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Removal of retained products of conception was the most common missing signal function for both basic and comprehensive PAC, followed by provision of any contraception (basic) or any LARC (comprehensive). Nearly 85% of women lived within 5 km of a facility providing any PAC services, while 50.5% and 17.4% lived within 5 km of a facility providing all basic PAC and all comprehensive PAC signal functions, respectively. Women with more education, greater wealth, and those living in urban areas had greater odds of living within 5 km of a facility with offering PAC, basic PAC, or comprehensive PAC. CONCLUSIONS: Results indicate a need for increased PAC availability and readiness, prioritizing basic PAC services at the primary level-the main source of care for many women-which would reduce structural disparities in access. The current deficiencies in PAC signal a need for broader strengthening of the primary healthcare services in Burkina Faso to reduce the burden of unsafe abortion-related morbidity and mortality while improving maternal health outcomes more broadly.

Reproductive autonomy and the experience of later-than-desired pregnancy: results from a cross-sectional survey of reproductive-aged women in Uganda.

BACKGROUND: The focus of reproductive autonomy research has historically been on the experience of unintended pregnancy and use of contraceptive methods. However, this has led to the neglect of a different group of women who suffer from constraints on their reproductive autonomy-women who experience pregnancies later than they desire or who are unable to become pregnant. This study examines the extent of later-than-desired pregnancy among women and evaluates the sociodemographic and reproductive factors associated with this experience in Uganda. METHODS: We use data from the Performance Monitoring for Action Uganda 2022 female survey. We restricted the nationally representative sample of reproductive-aged women to those who were currently pregnant or who had ever given birth (n = 3311). We compared the characteristics of women across fertility intention categories (wanted pregnancy earlier, then, later, or not at all) of their current or most recent birth and used multivariable logistic regression to examine factors independently associated with having a pregnancy later than desired compared to at a desired time. RESULTS: Overall, 28.3% of women had a later-than-desired pregnancy. Nearly all sociodemographic and reproductive characteristics were associated with the desired pregnancy timing of women's current or most recent pregnancy. Having higher education [adjusted odds ratio (aOR) 2.41, 95% confidence interval (CI) 1.13-5.13], having sought care for difficulties getting pregnant (aOR 2.12, 95% CI 1.30-3.46), and having less than very good self-rated health (good health aOR 1.74, 95% CI 1.12-2.71; moderate health aOR 1.77, 95% CI 1.09-2.86; very bad health aOR 4.32, 95% CI 1.15-16.26) were all independently significantly associated with increased odds of having a later-than-desired pregnancy. Being nulliparous (aOR 1.98, 95% CI 0.99-3.95) was also borderline significantly associated with having a later-than-desired pregnancy. CONCLUSIONS: Identifying those who have later-than-desired pregnancies is essential if we seek to make progress towards supporting women and couples in achieving their reproductive goals, not just preventing pregnancies. Research on desired pregnancy timing in sub-Saharan Africa should be expanded to capture later-than-desired pregnancies, a population which is invisible in existing data. This work has public health implications due to commonalities in the factors associated with mistimed and unintended pregnancies and their link to poorer health and potentially poorer pregnancy outcomes.

Exploring women's knowledge of abortion legality and association with source of abortion care using population-based survey data in Côte d'Ivoire and Ghana.

BACKGROUND: Knowledge of the conditions under which abortion is legal is important so that people can advocate for their right to abortion care. Yet minimal research has explored the association between women's knowledge of abortion legality and the induced abortion care they receive, particularly using population-based survey data. METHODS: Using national survey data collected by Performance Monitoring for Action (PMA) in Côte d'Ivoire and Ghana, we aimed to compare the prevalence of accurate knowledge of abortion legality, factors associated with knowledge of the law, and the association between knowledge of abortion legality and the source of women's induced abortion care in these two settings. We ran bivariate and multivariable logistic regressions to assess the relationships of interest. RESULTS: We found that awareness and knowledge of the abortion law were low in both Côte d'Ivoire and Ghana. In Cote d'Ivoire, women who were older, more educated, and with past abortion experience were more likely to be aware of the law. In Ghana, knowledge of the law did not vary significantly by demographic characteristics. However, in Ghana, knowledge of the law was correlated with women's use of the formal healthcare system for abortion care, with greater use of clinical sources in rural areas. CONCLUSIONS: It is possible that for populations with reduced access to abortion services, such as those in rural areas, knowledge of the law is advantageous for those seeking facility-based abortion care, particularly in settings where abortion is legal for a range of indications. Interventions seeking to improve access to facility-based abortion care in settings where abortion is legal on various grounds should incorporate education on the legal grounds for abortion.

Knowledge of the conditions under which abortion is legal is important for people to advocate for their right to abortion care, yet minimal research has explored the association between women's knowledge of abortion legality and the abortion care they receive, particularly using population-based survey data. Using national survey data collected by Performance Monitoring for Action (PMA) in Côte d'Ivoire and Ghana, we aimed to compare the prevalence of accurate knowledge of abortion legality, factors associated with knowledge of the law, and the association between knowledge of abortion legality and the source of women's abortion care in these two settings. We ran bivariate and multivariable logistic regressions to assess the relationships of interest. We found that awareness and knowledge of the abortion law were low in both Côte d'Ivoire and Ghana. In Côte d'Ivoire, knowledge was unequally distributed according to sociodemographic factors, while such inequities did not exist in Ghana. However, in Ghana, knowledge of the law was correlated with women's use of the formal healthcare system for abortion care, with greater use of clinical sources in rural areas. It is possible that for populations with reduced access to abortion services, such as those in rural areas, knowledge of the law is advantageous for those seeking facility-based abortion care, particularly in settings where abortion is legal for a range of indications. Interventions seeking to improve access to facility-based abortion care in settings where abortion is legal on various grounds should incorporate education on the legal grounds for abortion.

The Relationship Between Contraceptive Method Use and Return of Fecundity Among Women Attempting Pregnancy in Low- and Middle-Income Countries.

One of the most common barriers to using effective family planning methods is the belief that hormonal contraceptives and contraceptive devices have adverse effects on future fertility. Recent evidence from high-income settings suggests that some hormonal contraceptive methods are associated with delays in return of fecundity, yet it is unclear if these findings generalize to low- and middle-income populations, especially in regions where the injectable is widely used and pressure to bear children is significant. Using reproductive calendar data pooled across 47 Demographic and Health Surveys, we find that the unadjusted 12-month probability of pregnancy for women attempting pregnancy after discontinuing traditional methods, condoms, the pill, and the IUD ranged from 86% to 91%. The 12-month probability was lowest among those who discontinued injectables and implants, with approximately 1 out of 5 women not becoming pregnant within one year after discontinuation. Results from multivariable analysis showed that compared with users of either periodic abstinence or withdrawal, users of the pill, IUD, injectable, and implant had lower fecundability following discontinuation, with the largest reductions occurring among women who used injectables and implants. These findings indicate that women's concerns about potential short-term reductions in fecundity following contraceptive use are not unfounded.

Menstrual regulation: examining the incidence, methods, and sources of care of this understudied health practice in three settings using cross-sectional population-based surveys.

BACKGROUND: Menstrual regulation is a practice that may exist within the ambiguity surrounding one's pregnancy status and has been the subject of limited research. The aim of this study is to measure the annual rate of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by background characteristics and to describe the methods and sources women use to bring back their period. METHODS: Data come from population-based surveys of women aged 15-49 in each setting. In addition to questions on women's background characteristics, reproductive history, and contraceptive experiences, interviewers asked women whether they had ever done something to bring back their period at a time when they were worried they were pregnant, and if so, when it occurred and what methods and source they used. A total of 11,106 reproductive-aged women completed the survey in Nigeria, 2,738 in Cote d'Ivoire, and 5,832 in Rajasthan. We calculated one-year incidence of menstrual regulation overall and by women's background characteristics separately for each context using adjusted Wald tests to assess significant. We then examined the distribution of menstrual regulation methods and sources using univariate analyses. Method categories included surgery, medication abortion pills, other pills (including unknown pills), and traditional or "other" methods. Source categories included public facilities or public mobile outreach, private or non-governmental facilities or doctors, pharmacy or chemist shops, and traditional or "other" sources. RESULTS: Results indicate substantial levels of menstrual regulation in West Africa with a one-year incidence rate of 22.6 per 1,000 women age 15-49 in Nigeria and 20.6 per 1,000 in Cote d'Ivoire; women in Rajasthan reported only 3.3 per 1,000. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). CONCLUSION: These findings suggest menstrual regulation is not uncommon in these settings and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Menstrual regulation, or bringing back a late period, is an understudied practice that women may use when they are worried they are pregnant but that may be viewed as distinct from abortion. This study seeks to measure the frequency of menstrual regulation in Nigeria, Cote d'Ivoire, and Rajasthan, India, overall and by women's characteristics and to describe the methods and sources women use. We used data from representative surveys of women aged 15­49 years old in each study setting. We asked women whether they had ever done something to bring back a late period at a time when they were worried they were pregnant, and if so, what methods and sources they used. Results indicate that menstrual regulation may be a common practice, particularly in West Africa; the observed one-year rates were 22.6 menstrual regulations per 1,000 women aged 15­49 in Nigeria and 20.6 menstrual regulations per 1000 women in Cote d'Ivoire; women in Rajasthan only reported 3.3 menstrual regulations per 1000 women per year. Menstrual regulations primarily involved traditional or "other" methods in Nigeria (47.8%), Cote d'Ivoire (70.0%), and Rajasthan (37.6%) and traditional or "other" sources (49.4%, 77.2%, and 40.1%, respectively). These findings suggest menstrual regulation is not uncommon and may put women's health at risk given the reported methods and sources used. Results have implications for abortion research and our understanding of how women manage their fertility.

Postabortion care availability, readiness, and accessibility in Niger in 2022: results from linked facility-female cross-sectional data.

BACKGROUND: Postabortion care (PAC), which is an essential element of emergency obstetric care, is underresearched in Niger. The study aims to assess the availability, readiness, and accessibility of facility-based PAC services in Niger. METHODS: This study uses female and facility data from Performance Monitoring for Action Niger. The female data include a nationally representative sample of women aged 15-49 (n = 3,696). Using GPS coordinates, these female data were linked to a sample of public and private facilities (n = 258) that are expected to provide PAC. We assessed PAC availability and facility readiness to provide basic and comprehensive PAC using the signal functions framework, overall and by facility type. We then calculated the distance between women and their closest facility and estimated the proportion of women living within five kilometers (5 km) of a facility providing any PAC, basic PAC, and comprehensive PAC, overall and by women's background characteristics. RESULTS: Only 36.4% and 14% of eligible facilities had all basic and comprehensive PAC signal functions, respectively. Oxytocics and laparotomy were the most missing signal function for basic and comprehensive PAC, respectively. Private facilities were the least ready to provide the full range of PAC services. While 47% of women lived within 5 km of a facility providing any PAC services, only 33.4% and 7.9% lived within 5 km of a facility providing all basic and all comprehensive PAC signal functions, respectively. Women who were divorced/widowed, had higher levels of education, and were living in urban areas had increased odds of living within 5 km of a facility with any or basic PAC. Women who were never married had increased odds of living within 5 km of a facility with comprehensive PAC, while urban residence was fully predictive of living within 5 km of a facility with comprehensive PAC. CONCLUSIONS: This study found PAC availability and readiness to be insufficient in Niger, with inadequate and disparate accessibility to facilities providing PAC services. We recommended stakeholders ensure stock of essential commodities and availability of PAC services at primary facilities in order to mitigate the negative maternal health repercussions of unsafe abortion in this setting.

Abortion care availability, readiness, and access: linking population and health facility data in Kinshasa and Kongo Central, DRC.

BACKGROUND: The Democratic Republic of Congo (DRC) legalized abortion in 2018 to preserve health and pledged to provide quality postabortion care (PAC), yet little is known about the availability of abortion care services and if facilities are prepared to provide them; even less is known about the accessibility of these services. Using facility and population-based data in Kinshasa and Kongo Central, this study examined the availability of abortion services, readiness of facilities to provide them, and inequities in access. METHODS: Data on 153 facilities from the 2017-2018 DRC Demographic and Health Survey Service Provision Assessment (SPA) were used to examine signal functions and readiness of facilities to provide services across three abortion care domains (termination of pregnancy, basic treatment of abortion complications, and comprehensive treatment of abortion complications). To examine PAC and medication abortion provision before and after abortion decriminalization, we compared estimates from the 2017-2018 SPA facilities to estimates from the Performance Monitoring for Action (PMA) data collected in 2021 (n = 388). Lastly, we assessed proximity to PAC and medication abortion using PMA by geospatially linking facilities to representative samples of 2,326 and 1,856 women in Kinshasa and Kongo Central, respectively. RESULTS: Few facilities had all the signal functions under each abortion care domain, but most facilities had many of the signal functions: overall readiness scores were > 60% for each domain. In general, readiness was higher among referral facilities compared to primary facilities. The main barriers to facility readiness were stock shortages of misoprostol, injectable antibiotics, and contraception. Overall, provision of services was higher post-decriminalization. Access to facilities providing PAC and medication abortion was almost universal in urban Kinshasa, but patterns in rural Kongo Central showed a positive association with education attainment and wealth. CONCLUSION: Most facilities had many of the necessary signal functions to provide abortion services, but the majority experienced challenges with commodity availability. Inequities in accessibility of services also existed. Interventions that address supply chain challenges may improve facility readiness to provide abortion care services, and further efforts are needed to narrow the gap in accessibility, especially among poor women from rural settings.

Impact of the Trump Administration's Expanded Global Gag Rule Policy on Family Planning Service Provision in Ethiopia.

The Global Gag Rule (GGR) makes non-U.S. nongovernmental organizations (NGOs) ineligible for U.S. Government global health funding if they provide, refer, or promote access to abortion. This study quantitatively examines the impacts of the GGR on family planning service provision in Ethiopia. Using a panel of health facilities (2017-2020), we conduct a pre-post analysis to investigate the overall changes in family planning service provision before and after the policy came into effect in Ethiopia. Our pre-post analyses revealed post-GGR reductions in the proportions of facilities reporting family planning provision through community health volunteers (-5.6, 95% CI [-10.2, -1.0]), mobile outreach visits (-13.1, 95% CI [-17.8, -8.4]), and family planning and postabortion care service integration (-4.8, 95% CI: [-9.1, -0.5]), as well as a 6.1 percentage points increase in contraceptive stock-outs over the past three months (95% CI [-0.6, 12.8]). We further investigate the impacts of the GGR on facilities exposed to noncompliant organizations that did not sign the policy and lost U.S. funding. We do not find any significant additional impacts on facilities in regions more exposed to noncompliant organizations. Overall, while the GGR was slow to fully impact NGOs in Ethiopia, it ultimately resulted in negative impacts on family planning service provision.

Contraceptive Use Before and After Abortion: A Cross-Sectional Study from Nigeria and Côte d'Ivoire.

Post-abortion contraception enables women to effectively manage their fertility to prevent unintended pregnancies. Using data from population-based surveys of women aged 15-49 in Nigeria and Côte d'Ivoire, we examined contraceptive dynamics immediately before and after an abortion and examined factors associated with these changes using multivariable logistic regressions. Covariates included sociodemographic characteristics, abortion source, post-abortion contraceptive communication (wanting to and actually talking to someone about contraception after abortion), and perceived contraceptive autonomy. We observed higher contraceptive use after abortion than before abortion. In Nigeria, wanting to talk to someone about contraception post-abortion was associated with increased adoption and decreased discontinuation, whereas talking to someone about contraception post-abortion was associated with increased adoption. Obtaining care from a clinical abortion source was associated with increased adoption and decreased discontinuation. Both post-abortion contraceptive communication variables were associated with post-abortion contraceptive use in both countries, whereas clinical source was only associated with post-abortion contraceptive use in Nigeria. Our findings suggest that ensuring that women have access to safe abortion as part of the formal health care system and receive comprehensive, high-quality post-abortion care services that include contraceptive counseling enables them to make informed decisions about their fertility that align with their reproductive goals.

Social Network-Based Induced Abortion Incidence Estimation in Burkina Faso: Examining the Impact of the Network Generating Question.

Social network-based methods are increasingly used to estimate induced abortion incidence and investigate correlates. Approaches differ in the social tie definitions used to identify which social network members' abortion experiences respondents will report. This study compares the effect of using the "best friend" (closest female friend) versus "confidante" (specifying mutual sharing of personal information) definition on abortion incidence estimation. We use data from a nationally representative survey of women aged 15-49 in Burkina Faso (conducted in 2020-2021) where respondents were randomized into two versions of an abortion module, using different friend definitions. We computed abortion rate estimates by friend definition and adjusted for assumption violations (transmission bias, surrogate sample selection bias). Unadjusted incidence rates varied from 11.7 [4.1-19.2] abortions per 1,000 women to 15.6 [9.7-21.4], depending on friend definition. The confidante definition yielded higher adjusted estimates (36.2 [25.1-47.2]) than the best friend definition (17.0 [8.7-25.3]) due to greater transmission bias adjustment. Both estimates exceeded the respondent self-reported abortion incidence (4.0 [2.2-5.9]). Our results indicate that either friend definition produces higher incidence estimates than self-report but suggest a potential advantage for the "best friend" over the "confidante" definition given lower transmission bias. Further research should assess generalizability of these findings in other contexts.

How, when and where? A systematic review on abortion decision making in legally restricted settings in sub-Saharan Africa, Latin America, and the Caribbean.

BACKGROUND: With increasing global availability of medication abortion drugs, a safer option exists for many women to terminate a pregnancy even in legally restrictive settings. However, more than 22,000 women die each year from unsafe abortion, most often in developing countries where abortion is highly legally restricted. We conducted a systematic review to compile existing evidence regarding factors that influence women's abortion-related decision making in countries where abortion is highly legally restricted. METHODS: We searched ten databases in two languages (English and Spanish) for relevant literature published between 2000 and 2019 that address women's decision-making regarding when, where and how to terminate a pregnancy in sub-Saharan African, Latin American and the Caribbean countries where abortion is highly legally restricted. RESULTS: We identified 46 articles that met the review's inclusion criteria. We found four primary factors that influenced women's abortion-related decision-making processes: (1) the role of knowledge, including of laws, methods and sources; (2) the role of safety, including medical, legal and social safety; (3) the role of social networks and the internet, and; (4) cost affordability and convenience. CONCLUSIONS: The choices women make after deciding to terminate a pregnancy are shaped by myriad factors, particularly in contexts where abortion is highly legally restricted. Our review catalogued the predominant influences on these decisions of when, where and how to abort. More research is needed to better understand how these factors work in concert to best meet women's abortion needs to the full limit of the law and within a harm reduction framework for abortions outside of legal indications.

Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria and Côte d'Ivoire.

BACKGROUND: Unsafe abortions contribute to maternal mortality and morbidity worldwide, with disproportionate impacts in lower-income countries. Identifying factors associated with an elevated risk of experiencing an abortion under the most unsafe conditions is an important component of addressing this burden. The partner's role in obtaining a safe or unsafe abortion is not well understood. This study provides a quantitative assessment of the relationship between partner involvement and subsequent abortion safety. METHODS: The data are drawn from the PMA2020 female surveys and abortion follow-up surveys, fielded in Nigeria and Côte d'Ivoire between 2018 and 2020. The sample includes 1144 women in Nigeria and 347 women in Côte d'Ivoire who reported having ever experienced an abortion. We assess partner involvement in discussing the abortion decision and/or in selecting the method or source and evaluate the relationship between partner involvement and most unsafe abortion (using non-recommended methods from a non-clinical source) versus safe or less safe abortion, adjusting for sociodemographic characteristics. RESULTS: We find a strong association between experiencing any partner involvement and decreased odds of experiencing a most unsafe abortion (Nigeria: aOR = 0.34, 95% CI 0.26-0.45; Côte d'Ivoire: aOR = 0.27, 95% CI 0.16-0.47). Analyzing the two types of partner involvement separately, we find that partner involvement in the decision is associated with lower odds of most unsafe abortion in both countries (Nigeria: aOR = 0.48, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.34, 95% CI 0.19-0.60); partner involvement in selecting the method and/or source was only significantly associated with lower odds of most unsafe abortion in Nigeria (Nigeria: aOR = 0.53, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.65, 95% CI 0.32-1.32). CONCLUSION: In Nigeria and in Côte d'Ivoire, respondents whose partners were involved in their abortion trajectory experienced safer abortions than those whose partners were not involved. These findings suggest the potential importance of including men in education on safe abortion care and persistent need to make safe abortion accessible to all, regardless of partner support.

Typologies of women's abortion trajectories in Burkina Faso: findings from a qualitative study.

BACKGROUND: Abortion is a legally restricted, yet common reproductive life event among women in Burkina Faso; however, women's abortion experiences vary greatly depending on their social and economic capital, partner involvement, and level of knowledge. We sought to classify women's abortion care-seeking experiences across the life course and social conditions into typologies using qualitative data. METHODS: An initial quantitative survey among a nationally representative sample of women ages 15-49 years collected information on women's induced abortion experiences. Women who reported an abortion in the last 10 years were asked if they would agree to participate in a subsequent in-depth interview (IDI) to learn more about their abortion experience. Twenty-five women, identified via purposive sampling, completed an IDI. Using a process of typology construction, we identified attributes of each woman's condition at the time of her abortion and aspects of her abortion experience, created a matrix of attributes and cases, and identified emerging relationships. Three types were identified through this process. RESULTS: Twenty-three IDIs were analyzed, and women's abortion experiences were grouped into three types: abortion to delay childbearing in adolescence; abortion to space childbirth among women in union; abortion to avoid childbearing among single mothers. Two cases were identified as outliers. Cases were grouped based on the context of their pregnancy, the reason for the abortion and involved decision-makers, and their patterns of care-seeking, including methods and sources used. CONCLUSION: Structural inequities related to gender and wealth were prominent forces shaping women's abortion experiences. Comprehensive sexuality education coupled with community-based interventions to promote gender-equitable relationships and address social stigma related to women's sexuality could reduce reproductive coercion and unintended pregnancies.

A mixed-methods study exploring women's perceptions of terminology surrounding fertility and menstrual regulation in Côte d'Ivoire and Nigeria.

BACKGROUND: Women use various terms when discussing the management of their fertility and menstrual irregularities and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology used to refer to abortion-like experiences (specifically menstrual regulation and pregnancy removal), and the specific scenarios that these practices encompass among women who reported doing something to bring back a late period or ending a pregnancy in Nigeria and Côte d'Ivoire. METHODS: Our analysis draws upon surveys with women in Nigeria (n = 1114) and Cote d'Ivoire (n = 352). We also draw upon qualitative in-depth interviews with a subset of survey respondents in Anambra and Kaduna States in Nigeria, and Abidjan, Cote d'Ivoire (n = 30 in both countries). We examine survey and interview questions that explored women's knowledge of terminology pertaining to ending a pregnancy or bringing back a late period. Survey data were analyzed descriptively and weighted, and interview data were analyzed using inductive thematic analysis. RESULTS: We find that the majority (71% in Nigeria and 70% in Côte d'Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. CONCLUSIONS: Overall, menstrual regulation and pregnancy removal are seen as distinct experiences in both settings. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women's reproductive health needs.

Women use various words and phrases to describe their experiences managing their fertility and menstrual irregularities, and may interpret the experience of ending a possible pregnancy in nuanced ways, especially when their pregnancy status is ambiguous. Our study aims to understand the terminology women use to refer to abortion-like experiences (specifically menstrual regulation, which refers to actions taken to regulate a menstrual cycle, and pregnancy removal), and the specific scenarios that these practices encompass among women who reported having had an abortion in Côte d'Ivoire and Nigeria. Our analysis draws upon data from surveys and qualitative interviews conducted in both countries. We find that the majority (71% in Nigeria and 70% in Côte d'Ivoire) of women perceive menstrual regulation to be a distinct concept from pregnancy removal, yet there is considerable variability in whether specific scenarios are interpreted as referring to menstrual regulation or pregnancy removal. Menstrual regulation is generally considered to be more ambiguous and not dependent on pregnancy confirmation in comparison to pregnancy removal, which is consistently interpreted as voluntary termination of pregnancy. These findings have relevance for researchers aiming to document abortion incidence and experiences, and practitioners seeking to address women's reproductive health needs.

Determinants of women's preferred and actual abortion provision locations in Nigeria.

BACKGROUND: Unsafe abortion remains a leading cause of maternal mortality globally. Many factors can influence women's decisions around where to seek abortion care; however, little research has been done on abortion care decisions at a population-level in low-resource settings, particularly where abortion is legally restricted. METHODS: This analysis uses data from a 2019-2020 follow-up survey of 1144 women in six Nigerian states who reported an abortion experience in a 2018 cross-sectional survey. We describe women's preferred and actual primary abortion care provider/location by distinguishing clinical, pharmacy/chemist, or other non-clinical providers or locations. We also examine factors that influence women's decisions about where to terminate their pregnancy and identify factors hindering women's ability to operationalize their preferences. We then examine the characteristics of women who were not able to use their preferred provider/location. RESULTS: Non-clinical providers (55.0%) were more often used than clinical providers (45.0%); however, clinical providers were preferred by most women (55.6%). The largest discrepancies in actual versus preferred abortion provider/location were private hospitals (7.6% actual versus 37.2% preferred), government hospitals (4.3% versus 22.6%), chemists (26.5% versus 5.9%) and pharmacies (14.9% versus 6.6%). "Privacy/confidentiality" was the most common main reason driving women's abortion provider/location choice (20.7%), followed by "convenience" (16.9%) and "recommended" by someone (12.3%), most often a friend (60.8%), although top reasons differed by type of provider/location. Cost and distance were the two most common reasons that women did not use their preferred provider/location (46.1% and 21.9%, respectively). There were no statistically significant differences in the sociodemographic characteristics between women who were able to use their preferred provider/location and those who were not able to implement their preferred choice, with the exception of state of residence. CONCLUSIONS: These findings provide insights on barriers to abortion care in Nigeria, suggesting discretion is key to many women's choice of abortion location, while cost and distance prevent many from seeking their preferred care provider/location. Results also highlight the diversity of women's abortion care preferences in a legally restrictive environment.

Many factors influence a woman's pathway to obtaining an abortion, even in a setting with strict laws prohibiting the practice. This study aims to explore where women in Nigeria would prefer to and actually obtain their abortions, reasons why they could or could not use their preferred provider/location, and differences between women who were and were not able to use their preferred provider/location.The findings show that most women would opt to use a clinical source, such as a government or private hospital, especially among women who did not use their preferred source. Privacy/confidentiality, convenience, and recommendation from someone like a friend or partner drove women's abortion care preferences, although these influences differed by type of provider/location (clinical, pharmacy/chemist, or other non-clinical). Issues like cost, distance, and lack of privacy were barriers that prevented women from using their preferred provider/location, instead obtaining their abortion from a less desired provider. However, the sociodemographic characteristics of women who did and did not use their preferred provider/location did not differ significantly, except by state.These findings provide insights on barriers to safe abortion care in Nigeria, suggesting social safety drives many women to seek care outside of the healthcare system, while cost and distance prevented many from seeking clinical services. Results also highlight the diversity of women's abortion preferences in a setting where abortion is legally restricted.

Social network-based measurement of abortion incidence: promising findings from population-based surveys in Nigeria, Cote d'Ivoire, and Rajasthan, India.

BACKGROUND: Monitoring abortion rates is highly relevant for demographic and public health considerations, yet its reliable estimation is fraught with uncertainty due to lack of complete national health facility service statistics and bias in self-reported survey data. In this study, we aim to test the confidante methodology for estimating abortion incidence rates in Nigeria, Cote d'Ivoire, and Rajasthan, India, and develop methods to adjust for violations of assumptions. METHODS: In population-based surveys in each setting, female respondents of reproductive age reported separately on their two closest confidantes' experience with abortion, in addition to reporting about their own experiences. We used descriptive analyses and design-based F tests to test for violations of method assumptions. Using post hoc analytical techniques, we corrected for biases in the confidante sample to improve the validity and precision of the abortion incidence estimates produced from these data. RESULTS: Results indicate incomplete transmission of confidante abortion knowledge, a biased confidante sample, but reduced social desirability bias when reporting on confidantes' abortion incidences once adjust for assumption violations. The extent to which the assumptions were met differed across the three contexts. The respondent 1-year pregnancy removal rate was 18.7 (95% confidence interval (CI) 14.9-22.5) abortions per 1000 women of reproductive age in Nigeria, 18.8 (95% CI 11.8-25.8) in Cote d'Ivoire, and 7.0 (95% CI 4.6-9.5) in India. The 1-year adjusted abortion incidence rates for the first confidantes were 35.1 (95% CI 31.1-39.1) in Nigeria, 31.5 (95% CI 24.8-38.1) in Cote d'Ivoire, and 15.2 (95% CI 6.1-24.4) in Rajasthan, India. Confidante two's rates were closer to confidante one incidences than respondent incidences. The adjusted confidante one and two incidence estimates were significantly higher than respondent incidences in all three countries. CONCLUSIONS: Findings suggest that the confidante approach may present an opportunity to address some abortion-related data deficiencies but require modeling approaches to correct for biases due to violations of social network-based method assumptions. The performance of these methodologies varied based on geographical and social context, indicating that performance may be better in settings where abortion is legally and socially restricted.

Prevalence and Correlates of Perceived Infertility in Ghana.

Perceived infertility is an understudied phenomenon in low- and middle-income countries, where biomedical infertility can have severe consequences, particularly for women. We conducted a nationally representative survey of Ghanaian women, estimated the prevalence of and reasons for perceived infertility, and assessed factors associated with higher levels of perceived infertility using a partial proportional odds model. Among 4,070 women, 13 percent believed they were "very likely" to have difficulty getting pregnant when they wanted to, 21 percent believed this was "somewhat likely," and 66 percent believed this was "not at all likely." Reasons for perceived infertility varied by whether the respondent was currently seeking pregnancy. In multivariable analysis, several factors were associated with higher levels of perceived infertility, while unexpectedly, women who reported ever using contraception were less likely to report perceived infertility. Acknowledging the need to address infertility globally and understanding the role of perceived infertility are important components in supporting people's ability to decide whether and when to have children.

Can a List Experiment Improve Validity of Abortion Measurement?

Although induced abortion is common, measurement issues have long made this area of research challenging. The current analysis applies an indirect method known as the list experiment to try to improve survey-based measurement of induced abortion. We added a double list experiment to a population-based survey of reproductive age women in Rajasthan, India and compared resulting abortion estimates to those we obtained via direct questioning in the same sample. We then evaluated list experiment assumptions. The final sample completing the survey consisted of 6,035 women. Overall, 1.8 percent of the women reported a past abortion via the list experiment questions, whereas 3.5 percent reported an abortion via the direct questions, and this difference was statistically significant. As such, the list experiment failed to produce more valid estimates of this sensitive behavior on a population-based survey of reproductive age women in Rajasthan, India. One explanation for the poor list experiment performance is our finding that key assumptions of the methodology were violated. Women may have mentally enumerated the treatment list items differently from the way they enumerated control list items. Further research is required to determine whether researchers can learn enough about how the list experiment performs in different contexts to effectively and consistently leverage its potential benefits to improve measurement of induced abortion.